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32 How toSurgically Reconstruct Acute andChronic Burn Wounds inLow- andMiddle-Income Countries
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Figs. 32.111–32.114 A 20-year-old man with history of
ame burn to both legs and feet at the age of 6. Right heel
pad burned, was covered with STSG.Chronic pain from
right heel during walking had been a big problem ever
since. Heel reconstruction with cross-leg TFL ap
15years after the incident. No discomfort as he gradually
started walking during the next 3–4weeks
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E. Eriksen
Figs. 32.115–32.118 A 5-year-old boy involved in a
trafc accident resulting ina degloving injury with skin
loss at the Achilles and ankle region. The heel pad was
completely ripped off. Sheets of STSG were used to
coverthe Achilles and ankle area in advance of the TFL
ap procedure. Child recovered well
32 How toSurgically Reconstruct Acute andChronic Burn Wounds inLow- andMiddle-Income Countries
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Conclusion
Burns are the forgotten global public health crisis
(WHO 2013). In LMICs it injures more patients
than HIV and tuberculosis combined. We do
hope this chapter will encourage surgeons who
have sincere interest to help the many burn
victims in their communities. The techniques
needed for burn surgery depend only on a small
set of basic instruments; they are inexpensive.
Most of them will last for years once you have
got them.
Even though burns can happen to any part of
the body– from the scalp to the toes– the actual
surgical technique is rather simple. There are
some basic principles outlined in detail in this
chapter. The principles are applied the same way
in each procedure.
We hope that the reader of this chapter will
join the many individuals currently involved in
treating the unfortunate burn victims with modern burn care. The author has emphasized that
every burn patient will receive best professional
care by correctly applying the main building
material– the skin grafts– to the painful wounds.
The skin graft harvested from the patient himself
is the solution to the misery that burn patients
face after their injuries. Although a skin graft
appears easy and simple, it is a phenomenal product for those that search for help.
Provision of better early care in the acute/
early stage after burn injury will prevent subsequent disabilities that may be life-long and irreparable. Minimizing burn injuries is still the
ultimate goal of all modern societies.
How toManage Soft Tissue
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Infections andInjuries inLow-
33
andMiddle-Income Countries
ShailviGupta and JaclynClark
So often in life things that you regard as an impediment turn out to be great, good fortune.
– Ruth Bader Ginsburg
Abbreviations
LMICs Low- and middle-income countries
LRINEC Laboratory Risk Indicator for
Necrotizing Fasciitis
NSTI Necrotizing soft tissue infections
Introduction
Necrotizing soft tissue infections (NSTI) are
characterized by the presence of toxin-producing
bacteria, widespread tissue necrosis, and fulminant inammatory progression, leading to sepsis,
multiorgan failure, and, if untreated, death. The
mortality of this disease is high, estimated
between 20 and 30% even in the best of care.
Rapid identication and prompt surgical debridement of necrotic tissue are critical, and delays to
surgical intervention are associated with
S. Gupta (*)
University of Maryland School of Medicine, Capital
Region Health, Baltimore, MD, USA
e-mail: shailvi.gupta@som.umaryland.edu
J. Clark
University of Maryland School of Medicine, R
Adams Cowley Shock Trauma Center,
Baltimore, MD, USA
increased mortality [1–3]. Necrotizing infections
can occur after major traumatic injuries, as well
as after minor breaches of the skin or mucosa
(insect bites and abrasions), non-penetrating soft
tissue injuries (contusions), or routine surgical
procedures such as obstetrical and gynecological
procedures [1].
Diagnosis ofNSTI
Diagnosing NSTI versus other more common
clinical entities such as cellulites can be difcult.
Clinicians often rely upon physical examination,
diagnostic imaging, and clinical decision instruments to aid in diagnosing NSTIs. Classic physical examination signs described for NSTI include
erythema, soft tissue edema, severe pain (pain
out of proportion), fever, and hemorrhagic bullae.
Hypotension and shock can be indicators of
patients with NSTIs [4]. Various imaging modalities, if available, have also been utilized to help
aid in the diagnosis. Plain radiography may demonstrate gas within the soft tissue [3].
If available, laboratory values can be utilized
to aid in the diagnosis of NSTI.The Laboratory
Risk Indicator for Necrotizing Fasciitis
(LRINEC) score is a diagnostic clinical decision
instrument validated for differentiating NSTI
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_33
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S. Gupta and J. Clark.
from other soft tissue infections. LRINEC utilizes six laboratory values including white blood
cell count, hemoglobin, sodium, glucose, creatinine, and C-reactive protein. A score greater than
or equal to six indicates a “moderate” risk of
NSTI (50–75% probability), whereas a score
greater than or equal to 8 indicates a “high” risk
(greater than 75%) probability [3].
Necrotizing soft tissue infections are deadly
if left untreated and can be caused by a variety of
organisms. Necrotizing infection types I and II
are distinguished largely by whether the cause is
polymicrobial (type I) or monomicrobial (type II)
[1]. The polymicrobial Type I infections involve
aerobic and anaerobic organisms and are usually
seen in the elderly or in those with underlying
illnesses; predisposing factors can include diabetes, decubitus ulcers, rectal ssures, and colonic
or urologic or gynecologic procedures. Bacterial
penetration into the fascial compartments of the
head and neck may result in Ludwig’s angina
(infection of the submandibular fascial spaces),
which may be life-threatening by compressing
the trachea. The monomicrobial type II infection
is most commonly caused by gram-positive
organisms, with group A streptococcus being the
most common pathogen followed by methicillinresistant Staphylococcus aureus (MRSA). Type
II infections may occur in any age group and in
persons without any underlying illness [1] as may
type I infections.
Clostridial gas gangrene (clostridial myonecrosis) is caused by anaerobic, spore-forming
Clostridium subspecies, with Clostridium perfringens being the most common. It may occur
spontaneously, often with the background of
abdominal pathology or malignancy, or as a
result of traumatic injury [5]. Clostridium infection is synonymous with myonecrosis and is
characterized by rapidly progressive gangrene of
the injured tissue along with the production of
foul-smelling gas (like dead mouse). Historically
clostridial gas gangrene was observed as a complication of battleeld injuries. More recently,
trauma is responsible for the majority of cases;
other predisposing conditions are bowel and biliary tract surgery, intramuscular injection, retained
placenta, and intrauterine fetal death [1]. An
anaerobic environment is necessary for progression of clostridial infections, and therefore,
deeply penetrating injuries are more likely to
develop an infection than more supercial
wounds [6]. The potent bacterial exotoxins mediate the fulminant clinical features of the infection, and therefore clostridial myonecrosis is the
most rapidly spreading lethal infection in humans.
An immediate diagnosis and surgical debridement is the only way to save the patient’s life.
Invasive fungal wound infections are devastating infections due to the presence of angioinvasive molds (such as Mucorales, Aspergillus
species, and Fusarium species) [7]. The most
common mechanistic and clinical factors associated with these infections include dismounted
blast injury, above-knee traumatic amputations,
extensive perineal/pelvic injury, immunocompetence, and massive blood transfusions. Almost all
patients suffering from invasive fungal infections
have a suspicious wound, dened as recurrent tissue necrosis following at least two surgical
debridements. The hallmark of the diagnosis is
continued necrosis in well-debrided wounds, and
the mainstay of therapy is frequent aggressive
surgical debridement, with topical and parenteral
antifungal therapy [7].
Animal Bites
Animal bites are common worldwide. Based on
recent data, the most important factor in treating
animal bites is timely presentation to a medical
facility and/or physician, as patients presenting
1–2 days post bite carry a 3.5 and 7 times
increased relative risk of hospitalization or surgery respectively, compared to a patient who is
able to be medically treated the same day of the
bite [8]. Given that access to care may pose difculties in low- and middle-income countries
(LMICs) because of lack of roads and/or transportation, utilization of basic supportive care can
be implemented and is a powerful tool in LMICs.
Initial copious irrigation with saline or boiled
water, debridement, and wound culture are often
inexpensive and are within the algorithms of care
in nearly all animal bites. Irrigating the wound
33 How toManage Soft Tissue Infections andInjuries inLow- andMiddle-Income Countries
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with saline is an effective and readily accessible
initial treatment for bite wounds. This should be
followed by clinical assessment of the wound to
determine its depth and extent. Radiology studies
may be required if there is clinical concern for
fractures. Supportive treatment options should be
prioritized for animal bites as these are costeffective and can be provided in resource-limited
settings [9].
Given that various types of bites have different
risks, it is critical that the offending animal be
accurately identied to make sure that it is not a
bearer of any infectious disease, such as rabies, to
help guide medical and surgical algorithms.
Snakebites
Factors associated with increased snakebite prevalence include eld labor, male gender, and residence in rural areas; environmental factors
include monsoon seasons and evening hours. If
the animal cannot be identied, a patient’s presenting symptoms may prove useful in determining appropriate treatment interventions. Isolated
fang marks can indicate the presence of a venomous bite with a demonstrated sensitivity of 100%
and positive predictive value of 89%. The presence of multiple scratches, on the other hand, has
demonstrated a positive predictive value of 100%
of nonvenomous bites [9]. Symptoms largely
include pain and swelling with accompanying
erythema, ecchymosis, and paresthesia. Other
symptoms may include hemotoxicity, syncope,
neurotoxicity, ptosis, altered sensorium, and
breathlessness.
Antivenom is recognized as the rst-line treatment and is successful in the treatment of most
bites, though antivenom is expensive and may not
be accessible in LMICs. If antivenom is not available, ciprooxacin may be used to cover gramnegative Enterobacteriaceae and enterococci [9].
Additional maneuvers should include the removal
of clothing that may constrict the affected limb,
maintenance of a patent airway, systemic support, and immobilization of the bitten limb at a
level below the heart to prevent systemic spread.
Despite appropriate treatment, systemic compli-
cations may arise within the pulmonary, neurological, and renal organ systems as well as local
wound manifestations. Symptoms commonly
include hemorrhagic blisters, pulmonary edema,
compartment syndrome, cranial nerve paralysis,
stroke, and shock. Sequelae including respiratory
failure, dyspnea, systemic bleeding, sepsis, and
shock have been shown to be strongly associated
with fatal outcomes. Supportive care is critical in
the setting of snakebites [9].
Crocodile Bites
Crocodile bites are a relatively common injury
among people who live near rivers, estuaries, and
even lakes. Worldwide, there are 23 crocodile
species, but only one, Crocodylus niloticus (Nile
crocodile), is found in the 43 countries of tropical
Africa [10]. These areas of water where crocodiles inhabit are sources of sh and drinking
water and are used for washing and other domestic activities within surrounding communities.
Crocodile bites commonly present as a result of
penetrating, blunt, and shear forces, ranging from
minor scratches and punctures to amputations and
death, with deep punctures being the initial and
most common presentation. The severity of presentation is often linked to crocodile or alligator size
[9]. Despite a possibly small wound externally,
crocodile wounds are usually deep, with severe tissue damage, and are frequently contaminated with
unusual organisms, making them very difcult to
treat (Figs.33.1 and 33.2, reference 11].
The management of severe crocodile bites of
the limbs is a challenge to the surgeon for two
main reasons. Firstly, the bite injury is generally
of a crushing and degloving nature with multiple
wounds caused by the long rows of teeth. Small
supercial puncture wounds can mask signicant
muscle damage with or without an associated
fracture. Secondly, the wounds are contaminated
with the normal oral ora of a crocodile, which
consists of an unusual combination of bacteria.
These can cause aggressive local tissue damage,
as well as hemolysis. Thirdly, delay in referral
often occurs and can contribute independently to
the rate of complications [10].
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S. Gupta and J. Clark.
proximal
proximal
radial
distal
Fig. 33.1 Pre-operative patient photograph of the left
forearm showing a deep puncture wound in the proximal
part of the extensor compartment. Sand from the river
bank is noted as the wound had not been cleaned
ulnar
Initial management includes resuscitation,
tetanus prophylaxis, empirical broad-spectrum
antibiotics, and extensive surgical wound
debridement under general anesthesia. Signicant
hemorrhage should be controlled with direct
pressure and wound packing. If an associated
fracture is present, the use of an external xator
can greatly assist with ongoing wound care.
Repeated wound debridements are often necessary to control infection. Devitalized tissue
should be debrided, and the remaining wound
site should be left to heal by secondary intention
or delayed primary closure. Most complications
are related to serious deformities, reported in
40% of patients [9, 10].
Unusual gram-negative rods and anaerobes,
including Clostridia, are found as part of the normal ora of the crocodile’s mouth or are part of
marine ora and therefore may infect crocodile
bite wounds. Rhabdomyolysis can be seen in
patients, which may be due to toxic products and
enzymes released by microorganisms [10].
ulnar
radial
distal
Fig 33.2 Intra-operative photograph of the patients left
forearm post debridement demonstrating the extensive
muscle damage in the exor compartment and the depth
of the puncture which had transversed the interosseous
membrane and was visible within the exor compartment
(red arrow)
Some common pathogens include
Actinobacillus lignieresii treated with a combination of tetracycline or streptomycin and
potassium iodide, Streptococcus anginosus
treated with vancomycin, Streptococcus mutans
treated with ampicillin, Campylobacter ureo-
lyticus treated with azithromycin, Prevotella
melaninogenica treated with metronidazole,
and Bacteroides fragilis treated with metroni-
dazole [9].
Infections are usually polymicrobial bacteria,
however, and may be difcult to culture and
resistant to common antibiotics. Hemolysis can
be associated with ongoing infection, and the
hemoglobin should be monitored and the patient
transfused as required. Amputation should be
considered in view of the aggressive nature of the
infections involved and the frequently present
severe degree of tissue necrosis; amputation may
be a life-saving procedure [10].
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Spider Bites
Spider bites rarely cause medically relevant
harm to humans. Ones that do are typically isolated to regions of Australia, except for the
widow spider, Latrodectus. The venom pro-
duced by these spiders has been shown to cause
long-lasting systemic and regional pain, patchy
paralysis, agitation, and hypertension, among
other symptoms. Calcium derivates were used
historically to help relax the muscle, though
they have not been shown to be effective.
Antivenom has not been proven to be efcacious in the treatment of spider bites. Analgesics
are typically used and have demonstrated effectiveness toward limiting pain and should be the
primary method of treatment [9].
Rodent Bites
Rodent bites often occur during the summer
months at night and typically present on the
patient’s face and hands. The most common
pathogens include Pasteurella multocida, which
is treated with beta-lactams, beta-lactamase
inhibitors, and aggressive broad-spectrum antibiotics; Bacillus subtilis are treated with clindamycin and alpha-hemolytic Streptococcus treated
with beta-lactams and vancomycin [9].
Landmines
Civilian injury from land mines is a consequence
of modern warfare that unfortunately creates longlasting effects among its victims. Anti- personnel
landmines are an effective defensive weapon used
to slow the enemy or deny certain areas of land to
opposing personnel [12]. Their use, however,
indiscriminately kills both military personnel and
civilians alike. In addition to this, land mines leave
a signicant amount of land inaccessible to its
communities for decades following a conict [12].
It is estimated that at least 84 countries are infested
with land mines, with about 80 million land mines
buried worldwide [12, 13]. Most land mine vic-
tims, 80–90%, are noncombatants, mostly women
and children carrying on with activities of daily
living, and most living in LMICs, where access to
healthcare and other rehabilitation services can be
limited [14]. Land mine injuries often result in loss
of limb, disability, psychological disorders, and
loss of economic autonomy– affecting the victim
and his or her community for years following the
injury [12].
The severity of injury caused by antipersonnel
landmines depends on the type of land mine, the
proximity of the victim to the explosion, and the
relationship of the victim’s body to the mine at
the time of its detonation [12]. The International
Committee of the Red Cross (ICRC) has dened
three injury patterns caused by land mines.
Victims in Pattern I trigger an explosion by standing on a buried landmine. This usually causes a
traumatic amputation of a part of the lower limb
and less severe injury elsewhere. Such mines
consist of an explosive and may include fragments of metal or plastic. Pattern II injuries are a
random collection of penetrating injury caused
by multiple fragments from an exploding land
mine– injuries to the head, neck, or abdomen are
common. Pattern III injuries result from handling
a land mine, and victims tend to sustain severe
upper limb and facial injuries [15].
Common with other war wounds, land mine
injuries are frequently complicated by soft tissue
maceration and gross contamination with vegetation, clothing, and soil. The degree of contamination is usually much greater than is initially
apparent. Often, the wounds present late with
necrosis, perhaps sepsis, and possibly systemic
involvement [15]. The basic principle in treating
these wounds is to rst stop the hemorrhage and
then debride the wound extensively until healthy
tissue is present.
References
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necrotizing soft tissue infections. Infect Dis Clin N
Am. 2017;31:497–511.
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3. Fernando SM, Tran A, Cheng W, Rochwerg B,
Kyeremanteng K, Seely AJE, Inaba K, Perry
JJ.Necrotizing soft tissue infection: diagnostic accuracy of physical examination, imaging and LRINEC
score. Ann Surg. 2019;269(1):58–65.
4. Elliott DC, Kufera JA, Myers RA.Necrotizing soft
tissue infections. Risk factors for mortality and strategies for management. Ann Surg. 1996;224:262–83.
5. Yang Z, Hu J, Qu Y, et al. Interventions for treating gas gangrene. Cochrane Database Syst Rev.
2015;10(12):CD010577.
6. Buboltz JB, Murphy-Lavoie HM. Gas gangrene.
StatPearls Publishing; 2020.
7. Rodriguez CJ, et al. Treatment of suspected invasive fungal infection in war wounds. Mil Med.
2018;183:142–6.
8. Speirs J, Showery J, Abdou M, etal. Dog bites to the
upper extremity in children. J Paediatr Child Health.
2015;51:1172–4.
9. Savu AN, Schoenbrunner AR, Politi R, Janis
JE. Practical review of the Management of
Animal Bites. Plast Reconstr Surg Glob Open.
2021;9(9):e3778.
10. Wamisho BL, Bates J, Tompkins M, Islam R,
Nyamulani N, Ngulube C, Mkandawire NC. Ward
round – crocodile bites in Malawi: microbiology and surgical management. Malawi Med J.
2009;21(1):29–31.
11. Venter M, Kelly A, Boffard K, Pretorius R, Younus
A.African Nile crocodile bite of the forearm: a case
report. East Afr Orthopaed J. 2020;14(2)
12. Ryken KO, Hogue M, March JL, Schweizer M.Long
term consequences of landmine injury: a survey of
civilian survivors in Bosnia-Herzegovina 20 years
after the war. Injury Int J Care Inj. 2017;48:2688–92.
13. Walsh NE, Walsh WS. Rehabilitation of landmine
victims, the ultimate challenge. Bull World Health
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How toApproach NOMA andFacial
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Infections, Trauma, andTumours
Through Charity Missions:
TheOrigins ofFacing Africa
andLessons Learned
ChrisLawrence andTerryLawrence
We are here to add what we can to life, not to get what we can from life.
– William Osler
34
Abbreviations
CL Chris Lawrence
DNF Dutch Noma Foundation
FA Face Africa
MCM Myung Sung Christian Medical Center
MdS Marathon des Sables
TL Terry Lawrence
Introduction
In 1998, one of the authors (CL) watched a WHO
video about a disease called noma. It was so
shocking for him to see that such a disease,
related mainly by extreme poverty and malnutrition, should exist in the twentieth century and
that so few know anything about it. He learned
that noma was a bacterial infection that started in
the gums of children under the age of 6 and
spread very rapidly, and within 3–4weeks, it ate
away the lips and cheeks of small children. Noma
exists predominantly in sub-Saharan Africa, but
cases also appear in parts of SE Asia and South
C. Lawrence (*) · T. Lawrence
West Stowell House, Wiltshire, UK
e-mail: chris@facingafrica.org
America. The WHO estimated at that time that
250,000 cases of noma occurred globally every
year and that 90% of the victims would die within
weeks unless it was diagnosed and cured with an
antibiotic in the very early stages. Noma remains
a disease still ofcially unrecognized by WHO
and by most professionals. A large number of
NGOs are still trying desperately to persuade the
WHO to include noma in its listings of diseases.
Those who survive the ravages of this esheating disease are left with gaping holes in their
cheeks, nose and lips, thus causing terrible discomfort, pain, difculty in drinking and eating
and of course social rejection. Noma is usually
considered a curse or a punishment from God,
and as a result, the parents keep their affected
children in the shadows out of shame. Since most
Africans living in rural areas are often illiterate
and know little of anything about doctors and
hospitals, most of the parents’ rst port of call is
to a “traditional healer” (witch doctors in our
language), since the parents cannot afford the bus
fare to a regional clinic or hospital.
One of the authors (CL) along with his wife,
despite no medical background, were inspired
and compelled to nd a solution to this chilling
disorder. The Dutch Noma Foundation (DNF)
and Dr. Klaas Marck, an eminent Dutch surgeon
who had been doing reconstructive surgery on
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_34
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